Provider Demographics
NPI:1619375235
Name:NIELSON, LINDA MAXINE (RN)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:MAXINE
Last Name:NIELSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:MAXINE
Other - Last Name:RICKETTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1593 HEWITT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-1221
Mailing Address - Country:US
Mailing Address - Phone:651-645-9424
Mailing Address - Fax:651-645-3216
Practice Address - Street 1:1593 HEWITT AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-1221
Practice Address - Country:US
Practice Address - Phone:651-645-9424
Practice Address - Fax:651-645-3216
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-13
Last Update Date:2014-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 1080210323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility